A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?
“You shouldn’t feel any pain since the local area is anesthetized.”
“Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.”
“Most clients report more discomfort from the preparation than from the procedure itself.”
“You may feel some cramping during the procedure.”
The Correct Answer is D
Choice A: “You shouldn’t feel any pain since the local area is anaesthetized.” This is not a response that the nurse should make to the client who is scheduled for a colonoscopy. The nurse should not tell the client that they will not feel any pain, as this may create unrealistic expectations and increase anxiety if they do experience discomfort. The nurse should also not tell the client that the local area is anaesthetized, as this is not true. The client does not receive local anesthesia for a colonoscopy, but rather sedation and pain medication.
Choice B: “Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.” This is not a response that the nurse should make to the client who is scheduled for a colonoscopy. The nurse should not tell the client not to worry, as this may sound dismissive and insensitive to their concerns. The nurse should also not tell the client that they will not remember anything about the procedure, as this is not true. The client may receive conscious sedation for a colonoscopy, which means that they are awake but drowsy and relaxed. They may have some memory loss of the procedure, but they are not completely unconscious.
Choice C: “Most clients report more discomfort from the preparation than from the procedure itself.” This is not a response that the nurse should make to the client who is scheduled for a colonoscopy. The nurse should not compare the client’s experience to other clients, as this may minimize their feelings and individual differences. The nurse should also not focus on the preparation, which involves drinking a large amount of liquid laxative to empty the colon, as this may increase anxiety and dread for the client. The nurse should instead focus on providing information and support for both the preparation and the procedure.
Choice D: “You may feel some cramping during the procedure.” This is a response that the nurse should make to the client who is scheduled for a colonoscopy, which is a diagnostic test that uses a flexible tube with a camera to examine the colon and rectum. The nurse should inform the client that they may feel some cramping during the procedure as the tube is inserted and moved through the colon. The nurse should also reassure the client that they will receive sedation and pain medication to make them comfortable and relaxed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Potassium 2.5 mEq/L. This is the priority data collection finding that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should identify potassium 2.5 mEq/L as the priority because it indicates hypokalemia, which is a low level of potassium in the blood. Potassium is an electrolyte that regulates the electrical activity of the heart and muscles. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis, which can be life-threatening.
Choice B: Blood glucose 150 mg/dL. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Blood glucose 150 mg/dL indicates hyperglycemia, which is a high level of glucose in the blood. Hyperglycemia can be caused by dehydration, stress, infection, or medication side effects.
Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, and fatigue. It can also lead to complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state, which are serious but not as urgent as hypokalemia.
Choice C: Urine specific gravity 1.035. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Urine specific gravity 1.035 indicates concentrated urine, which can be caused by dehydration or fluid loss. Dehydration can result from vomiting and diarrhea, which are common symptoms of acute gastroenteritis. Dehydration can cause symptoms such as dry mucous membranes, tachycardia, hypotension, and oliguria. It can also lead to complications such as shock or kidney failure, which are serious but not as urgent as hypokalemia.
Choice D: Weight loss of 3% of total body weight. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Weight loss of 3% of total body weight indicates mild to moderate dehydration, which can be caused by fluid loss from vomiting and diarrhea. Weight loss can also reflect loss of muscle mass or fat tissue due to malnutrition or inflammation. Weight loss can affect the client’s nutritional status and immune function, but it is not as urgent as hypokalemia.
Correct Answer is A
Explanation
Choice A: Determine the client’s calcium level. This is the priority action for the nurse to take because the client might have hypocalcemia, which is a low level of calcium in the blood. Hypocalcemia can occur after a thyroidectomy due to accidental removal or damage of the parathyroid glands, which regulate calcium levels. Hypocalcemia can cause muscle spasms, tetany, paresthesia, and seizures.
Choice B: Give the client an oral potassium supplement. This is not an appropriate action for the nurse to take because the client might have hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can also occur after a thyroidectomy due to damage to the adrenal glands, which regulate potassium levels. Hyperkalemia can cause muscle weakness, arrhythmias, and cardiac arrest.
Choice C: Administer intravenous normal saline solution. This is not a necessary action for the nurse to take because the client does not have signs of dehydration or fluid imbalance. Normal saline solution does not affect calcium or potassium levels.
Choice D: Monitor the client’s peripheral pulses. This is an important action for the nurse to take, but not the priority. The nurse should monitor the client’s peripheral pulses for signs of decreased perfusion or ischemia, which can result from hypocalcemia or hyperkalemia affecting the cardiac function. However, this should be done after determining the client’s calcium level and correcting it if needed.
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